Nursing Elites

1. A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?

• A. Administering an antiviral agent
• B. Clustering care to conserve energy
• C. Offering oral fluids to promote hydration
• D. Providing an antitussive agent when necessary

Correct answer: B

Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is clustering care to conserve energy. Infants with RSV often struggle to breathe and require rest periods to recover. Clustering care involves organizing nursing activities to allow for rest intervals, reducing the infant's energy expenditure and aiding recovery. Administering antiviral agents is not the primary intervention for RSV since it is a viral infection, and antiviral medications may not be effective against RSV. While offering oral fluids is crucial for hydration, it may not be the priority when the infant is having respiratory difficulties. Providing an antitussive agent when necessary can help with coughing but is not the priority intervention for managing RSV in this scenario.

2. What finding would the nurse expect to assess in a child with hypothyroidism?

• A. Nervousness
• B. Heat intolerance
• C. Smooth velvety skin
• D. Weight gain

Correct answer: D

Rationale: Weight gain is the expected finding in a child with hypothyroidism. Hypothyroidism leads to a slowed metabolism, which can result in weight gain. Choices A, B, and C are not typical findings in hypothyroidism. Nervousness and heat intolerance are more commonly associated with hyperthyroidism, where the body is in a state of overactivity. Smooth velvety skin is not a characteristic sign of hypothyroidism.

3. At 7 AM, a healthcare professional receives the information that an adolescent with diabetes has a 6:30 AM fasting blood glucose level of 180 mg/dL. What is the priority nursing action at this time?

• A. Encourage the adolescent to start exercising.
• B. Ask the adolescent to obtain an immediate glucometer reading.
• C. Inform the adolescent that a complex carbohydrate such as cheese should be eaten.
• D. Tell the adolescent that the prescribed dose of rapid-acting insulin should be administered.

Correct answer: D

Rationale: The correct priority nursing action in this situation is to administer the prescribed dose of rapid-acting insulin. Rapid-acting insulin is necessary to help lower the elevated blood glucose level quickly, thereby preventing potential complications of hyperglycemia. Encouraging exercise, obtaining a glucometer reading, or suggesting consumption of complex carbohydrates like cheese may not address the immediate need to bring down the high blood glucose level effectively. Exercise could potentially raise blood glucose levels, obtaining a glucometer reading may delay necessary treatment, and consuming complex carbohydrates can further elevate blood glucose levels in this scenario.

4. A healthcare provider is preparing a 2-year-old child for surgery. What preoperative teaching should be provided to this child?

• A. Explaining the procedure in simple terms
• B. Using a doll to demonstrate the procedure
• C. Showing pictures of the hospital environment
• D. Allowing the child to play with medical equipment

Correct answer: B

Rationale: Using a doll to demonstrate the procedure is the most appropriate preoperative teaching method for a 2-year-old child. It helps them understand what to expect in a non-threatening way by providing a visual representation of the upcoming surgery. Explaining the procedure in simple terms may be too abstract for a child of this age, as they may not fully comprehend verbal explanations. Showing pictures of the hospital environment may not be as effective as using a doll, as it may not provide a concrete understanding of the actual procedure. Allowing the child to play with medical equipment is unsafe and does not adequately prepare them for the surgery, as it may lead to misunderstandings or fear regarding the equipment's actual use during the surgery.

5. What is the priority nursing responsibility when a 3-year-old child in a crib is experiencing a tonic-clonic seizure with a clamped jaw?

• A. Apply restraints.
• B. Administer oxygen.
• C. Protect the child from self-injury.
• D. Insert a plastic airway in the child’s mouth.

Correct answer: C

Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints (Choice A) can cause harm by restricting movement during the seizure. While administering oxygen (Choice B) may be necessary, it is not the immediate priority during an active seizure. Inserting a plastic airway (Choice D) is contraindicated as it can lead to injury and is not recommended during a seizure. Protecting the child from self-injury (Choice C) is crucial to prevent harm from uncontrolled movements and potential falls, ensuring the safety of the child.

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